The sequence of events that occurred as the pilot's weight was taken by the pilot ladder is consistent with an upper step of the ladder having been hung up on the shell plating. It is likely that, when the ladder was rigged, it was secured with one of the steps bearing on the upper edge of a doubling plate. However, this was observed neither by the deck watch officer at the time of the rigging nor by the pilot before its use. The weight and movement of the pilot dislodged the step, allowing the ladder to drop until the slack and the weight was taken by the side ropes. A ladder that has been properly rigged and secured would not be subject to a re-adjusting drop when weight is applied to it, and wet conditions would not be a contributing factor. There is conflicting information regarding the rigging of the ladder and the amount of slippage as the pilot descended. The ship's staff reported that the steps could not have slipped more than about one foot, and they were conscious of the ladder running out. The pilot reported hearing the slopping of the treads as they released. The ship's staff report the ladder to have been made fast on the rail and normally the ropes at the top of the ladder are used for this purpose. The pilot reported seeing the standing part of the ladder lying on the deck, which could not be normal if the top ropes were used to secure the ladder on the rail. With the vessel at a loaded draught of 26 ft and a moulded depth of 50 ft, the freeboard would be about 24 ft. This, combined with a pilot boat freeboard of about 4 ft, would give a net length of ladder of approximately 20 ft. Having progressed about 7 to 8 ft below the main deck, the fall would have been about 12 ft. Man-ropes had not been rigged, and they are not always the preferred handgrip of persons using a rope ladder because they allow the body to move away from the surface against which the ladder is leaned. The use of man-ropes is a contentious issue among pilots; while some prefer their use, others do not. At pilot boarding stations which are exposed to sea swell, and particularly in adverse weather conditions, the use of man-ropes could enhance safety. On the other hand, man-ropes tend to blow and flap loosely across the ladder with the wind and could become fouled on the ladder fittings or the pilot boat. Since the pilot indicated that he did not require the use of man-ropes, they were not made available but they would have been rigged had the pilot so desired. The stowage of the ladder during loading operations subjected it to gypsum dust, although this is not considered to have been a factor in this occurrence. The location of the lowest batten indicates that the construction of the pilot ladder was not in accordance with regulatory guidelines. However, this is not considered to have been a contributing factor in this occurrence.Analysis The sequence of events that occurred as the pilot's weight was taken by the pilot ladder is consistent with an upper step of the ladder having been hung up on the shell plating. It is likely that, when the ladder was rigged, it was secured with one of the steps bearing on the upper edge of a doubling plate. However, this was observed neither by the deck watch officer at the time of the rigging nor by the pilot before its use. The weight and movement of the pilot dislodged the step, allowing the ladder to drop until the slack and the weight was taken by the side ropes. A ladder that has been properly rigged and secured would not be subject to a re-adjusting drop when weight is applied to it, and wet conditions would not be a contributing factor. There is conflicting information regarding the rigging of the ladder and the amount of slippage as the pilot descended. The ship's staff reported that the steps could not have slipped more than about one foot, and they were conscious of the ladder running out. The pilot reported hearing the slopping of the treads as they released. The ship's staff report the ladder to have been made fast on the rail and normally the ropes at the top of the ladder are used for this purpose. The pilot reported seeing the standing part of the ladder lying on the deck, which could not be normal if the top ropes were used to secure the ladder on the rail. With the vessel at a loaded draught of 26 ft and a moulded depth of 50 ft, the freeboard would be about 24 ft. This, combined with a pilot boat freeboard of about 4 ft, would give a net length of ladder of approximately 20 ft. Having progressed about 7 to 8 ft below the main deck, the fall would have been about 12 ft. Man-ropes had not been rigged, and they are not always the preferred handgrip of persons using a rope ladder because they allow the body to move away from the surface against which the ladder is leaned. The use of man-ropes is a contentious issue among pilots; while some prefer their use, others do not. At pilot boarding stations which are exposed to sea swell, and particularly in adverse weather conditions, the use of man-ropes could enhance safety. On the other hand, man-ropes tend to blow and flap loosely across the ladder with the wind and could become fouled on the ladder fittings or the pilot boat. Since the pilot indicated that he did not require the use of man-ropes, they were not made available but they would have been rigged had the pilot so desired. The stowage of the ladder during loading operations subjected it to gypsum dust, although this is not considered to have been a factor in this occurrence. The location of the lowest batten indicates that the construction of the pilot ladder was not in accordance with regulatory guidelines. However, this is not considered to have been a contributing factor in this occurrence. Apparently the pilot ladder had been secured without ensuring that it had been properly ranged down the ship's side. Supervision of the rigging of the pilot ladder by the deck watch officer did not detect the slack in the upper part of the pilot ladder nor was it detected by the pilot before its use. Man-ropes had not been rigged and were not specifically requested by the pilot. The pilot's preferred option was not to use the man-ropes. The pilot ladder in use did not meet the regulatory requirements and the steps of the pilot ladder were secured such that they did not provide consistently horizontal surfaces. Although the pilot considered the condition of the pilot ladder to be poor on the inbound trip, he did not indicate his reluctance to use the same ladder on the outward trip.Findings Apparently the pilot ladder had been secured without ensuring that it had been properly ranged down the ship's side. Supervision of the rigging of the pilot ladder by the deck watch officer did not detect the slack in the upper part of the pilot ladder nor was it detected by the pilot before its use. Man-ropes had not been rigged and were not specifically requested by the pilot. The pilot's preferred option was not to use the man-ropes. The pilot ladder in use did not meet the regulatory requirements and the steps of the pilot ladder were secured such that they did not provide consistently horizontal surfaces. Although the pilot considered the condition of the pilot ladder to be poor on the inbound trip, he did not indicate his reluctance to use the same ladder on the outward trip. The pilot ladder had not been properly rigged or secured to allow a safe disembarking. Slack, in the upper part of the ladder, above the step on which the pilot stood, allowed the ladder to slip, drop, and suddenly fetch up, jolting the pilot's grip loose from the side ropes, causing him to fall to the deck of the pilot boat below. Contributing to the occurrence was the fact that the supervision of the rigging and securing of the pilot ladder by the deck watch officer and observations of the ladder by the pilot before its use did not detect improper rigging of the pilot ladder.Causes and Contributing Factors The pilot ladder had not been properly rigged or secured to allow a safe disembarking. Slack, in the upper part of the ladder, above the step on which the pilot stood, allowed the ladder to slip, drop, and suddenly fetch up, jolting the pilot's grip loose from the side ropes, causing him to fall to the deck of the pilot boat below. Contributing to the occurrence was the fact that the supervision of the rigging and securing of the pilot ladder by the deck watch officer and observations of the ladder by the pilot before its use did not detect improper rigging of the pilot ladder. As result of this occurrence, the owner of the vessel has taken the following actions: The pilot boarding area was moved to midships. A chafing bar was installed at the sheer strake. Steel lug support brackets have been installed to facilitate four-point ladder fastening. The ship's pilot ladders have been replaced with ladders of better quality.Safety Action As result of this occurrence, the owner of the vessel has taken the following actions: The pilot boarding area was moved to midships. A chafing bar was installed at the sheer strake. Steel lug support brackets have been installed to facilitate four-point ladder fastening. The ship's pilot ladders have been replaced with ladders of better quality.